'It does affect more than your lungs': Why COVID-19 survivors may need to get screened for heart damage

While COVID-19 is known as a respiratory infection, there's emerging evidence linking it to heart damage, too.

Cardiologists are seeing patients with signs of inflammation and scar formation in their hearts even after recovery from COVID-19, experts say.

For that reason, anyone who plans on participating in vigorous exercise and was sick with COVID-19 for three or more days should get a cardiac screening before working out or participating in their sport, said Dr. Steven Erickson, medical director for Banner University Sports Medicine and Concussion Specialists in Phoenix.

"You don't get sick with COVID-19 and stay home from school for a week and the next day go back and play two hours of soccer," Erickson said.

"You're taking a risk, and that is not what the medical community is recommending right now." 

Having assessed seriously ill COVID-19 inpatients since March, Mayo Clinic in Arizona cardiologist Dr. Dawn Pedrotty said she has seen evidence linking the disease with cardiac damage.

What's not clear is what that damage will mean for patients in the long term, but researchers and physicians are closely following the link, she said.

"There is a connection to heart disease. It's not just a respiratory disease," Pedrotty said. "It's an important public health message that it does affect more than your lungs."

Screening criteria include illness for 3 days

People who have been sick with COVID-19 for three days or more should get a blood test and an EKG, also known as an electrocardiogram, before returning to strenuous exercise, Erickson said.

An electrocardiogram measures the heart's electrical signal. The blood test Erickson recommends measures troponin proteins, which are normally found in the heart muscle but released into the bloodstream when the heart is injured.

All athletes should be symptom-free for at least 14 days before resuming sports and should resume activities gradually while being monitored for cardiac symptoms, he added.

If patients are competitive athletes who will be training or participating in an upcoming sports season and had COVID-19, Erickson recommends they seek an evaluation with their primary care physician or sports medicine specialist to see if they need additional evaluation by a cardiologist.

Recent studies about heart damage and COVID-19 in athletes gained attention in recent weeks as college sports leaders debated returning to play. 

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An Ohio State University study published in a Sept. 11 research letter in JAMA, a prominent medical journal, found four of 26 competitive male and female college athletes who had tested positive for COVID-19 showed signs of myocarditis, a disease of the heart muscle that can cause heart failure and sudden cardiac death.

The athletes were screened with cardiac magnetic resonance imaging, which is a highly sensitive test.

Having 15% of athletes show signs of myocarditis raised concern among some who read the study. But the study sample was so small that some critics have said the alarm has been overstated.

"It is believed that there are many different organs in the body that are affected by the virus. After infection, the virus goes to different organs and tissues and after entering them it causes an inflammatory response," said Chris Glembotski, a professor of internal medicine and director of the Translational Cardiovascular Research Center at the University of Arizona College of Medicine in Phoenix.

"This inflammatory response seems to be an over-response, almost like too much inflammation. Usually, a little inflammation is good if you get an infection because it helps you fight off the infection. But this seems to be a hyper response, which directly or indirectly affects numerous organs in the body."

The respiratory system and the heart are focal points of the response, Glembotski said.  There's also evidence that the SARS-CoV-2 virus that causes COVID-19 can directly infect the heart and cause arrhythmias and, in some cases, contribute to symptoms that mimic a myocardial infarction, or heart attack, Glembotski said.

"There have been cases of some brain problems, a few cases of stroke and brain fog where people report that they have a general feeling that their thinking is not as good as it was before COVID-19. Among the things that are so worrisome about SARS-CoV-2 is that it has such widespread effects in the body, and the spectrum of its effects are so different from one person to the next," he said.

"Most of what we are learning about COVID-19 is from research emerging currently, so not a lot is known. There's more to be found out."

Avoiding sudden cardiac death in young athletes

Erickson said the aim of his recommendation for athletes is to prevent sudden cardiac death and to prevent long-term damage from COVID-19. The evidence may not be conclusive, but when the risk is death, it's better to do more than less, he said.

His advice comes from emerging research such as the Ohio study that is not definitive yet suggests an association between COVID-19 and cardiac problems, chiefly myocarditis.

Myocarditis may cause shortness of breath and symptoms of congestive heart failure. It can cause arrhythmia, which is an irregular heartbeat that reduces the heart's ability to pump blood and cause someone to collapse and even die.

Erickson is the first to say the research to date is not conclusive, but he doesn't want to take chances. Myocarditis is of particular concern in athletes because it is associated with a higher-than-average rate of sudden cardiac death.

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It's doubtful that athletes have more of a tendency for myocarditis than the regular population, but the stress of constant exercise means the myocarditis can manifest more severely in them.

"Somebody that is not participating in vigorous cardiovascular exercise doesn't need to be screened," Erickson said.

"But anyone, including your middle-aged marathon runner, absolutely we think they need to be screened after they recover from COVID before they go back to vigorous exercise because we don't want them to damage their heart or have sudden cardiac death."

Pedrotty of the Mayo Clinic agrees with Erickson's recommendation to do routine cardiac screening on high-functioning athletes of all ages who have been sick with COVID-19 for three days or more.

She might add testing for c-reactive protein in addition to looking for troponin in a blood test, she said, because c-reactive protein is a measure of inflammation.

Doctor: Asymptomatic COVID-19 patients likely not at risk

Heart damage is unlikely in someone who has tested positive for COVID-19 yet had no symptoms, nor is it likely in anyone who was sick with the virus for fewer than three days, Erickson said.

Those individuals do not need cardiac screenings, he said.

Erickson, who serves on the Arizona Interscholastic Association advisory board, is writing a set of "return to play" guidelines for primary care and emergency department physicians within Banner, which is Arizona's largest health care delivery system.

The AIA announced last week that football will resume this fall, along with other fall sports, after a key metric was adjusted. 

Myocarditis a big concern for young athletes

Myocarditis as a result of viral infections like HIV and Coxsackie B virus, while rare, has long been a concern for cardiologists. The risk of myocarditis is one of the reasons the general recommendation for sports medicine is that no one with a fever of 101.5 or more should exercise, Erickson said.

"The risk of playing is that the virus could spread to the heart and you could have myocarditis," he said

The COVID-19 pandemic has heightened the concern over myocarditis because the viral disease is so new and its long-term effects remain uncertain.

"We don't see a lot of myocarditis in general. But the reason it's particularly important in athletes and exercise is that it's one of the more common causes of sudden death in young athletes," said Dr. R. Todd Hurst, a cardiologist with the Banner University Medicine Heart Institute.

"Maybe up to 20% of sudden death in a young athlete is subsequently diagnosed as myocarditis. When we have a patient that has been diagnosed with myocarditis, the recommendation is that they not participate in strenuous exercise for three to six months."

'I worry about my heart'

Various early studies of COVID-19 patients have shown evidence of myocardial damage in anywhere from 5% to 25% of the patients who were hospitalized, which Hurst said is enough to indicate there is something "concerning" about the new coronavirus and the heart.

"There is a level of concern out there that there may be ongoing issues from COVID that we don't fully understand yet. Even after the infection is resolved, there are anecdotal reports of people that are still battling fatigue and other symptoms, and whether that warrants a heart evaluation, I don't know the answer," Hurst said.

"But if I saw a patient like that, that had those ongoing symptoms — they were short of breath, they were fatigued, they didn't have the energy — I certainly think a cardiac screening evaluation for them would at least make sense."

Christopher Ruggles, a 49-year-old dog walker who lives in Peoria, said he's been living with COVID-19 symptoms since mid-March. He wasn't able to get a test during the early weeks of his illness and has since tested negative three times. An antibody test came up negative, too.

But Ruggles can't think of any other cause for his lingering fatigue, cough and muscle weakness that has left him unable to work. While he normally was walking 10 to 12 miles a day, he can now barely do 30 minutes of yoga, he said.

Ruggles just connected with a third doctor. The first two did not take his symptoms seriously, but he persisted. He's part of a COVID "long-haulers" group for people with residual problems from the virus and he is hoping to get a cardiac MRI. An EKG did not show any heart damage, but Ruggles remains concerned.

"I worry about my heart," he said.

Heart symptoms include 'decreased exercise tolerance'

Any COVID-19 survivor who has lingering symptoms like heart palpitations that could indicate heart trouble should follow up with a cardiologist, said Dr. Pallavi Bellamkonda, a cardiologist with the Heart and Vascular Institute at Dignity Health St. Joseph’s Hospital and Medical Center in Phoenix.

Similarly, Pedrotty of the Mayo Clinic said she has a patient who had COVID-19 and recovered at home but is now experiencing chest tightness. A stress test was negative and Pedrotty is now looking for "residual inflammation."

"For those patients, we do recommend a cardiac MRI," she said. "Obviously the (medical) societies have not all put out guidelines. It's a bit premature, but I think a lot of us suspect that if we do have COVID patients that have subsequently recovered and now have symptoms, an MRI is appropriate."

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Bellamkonda said other symptoms COVID-19 survivors should watch for that could signal heart trouble include persistent chest pains, shortness of breath and once they are fully recovered a "decrease in exercise tolerance" —  not being able to do something like run a mile that a person could easily do prior to getting sick, for example.

Pedrotty said COVID-19 is not just a cardiac disease: It's cardiovascular, too, which means it could involve the body's blood vessels.

"There have been a lot of studies published about patients having clots and pulmonary embolisms and all of these types of things that have happened, especially in the severely ill," she said.

"We're just starting trials to understand the hematologic aspects of this. We know there's some endothelial damage, and that's what lines all your blood vessels."

Not everyone who has had COVID-19 needs a cardiac screening, but the illness can cause extreme reactions in the body, she added.

"That is partly why we suspect we're seeing some of the damage," she said. "It's a much more extreme response from your body than we see with the flu. With your flu you get sick, you can have systemic illness, especially with the elderly and immune-compromised. But it's not to the level of what we're seeing with COVID."

Reach health care reporter Stephanie Innes at Stephanie.Innes@gannett.com or at 602-444-8369. Follow her on Twitter @stephanieinnes.

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